Intake for Center therapeutic services
Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Please fill out this form before your first session. It will be automatically sent to your therapist.
First and Last Names (legal) * *
Your answer
Preferred Name
Your answer
Name of parent/guardian (if under 18 years)
Your answer
Street Address
Your answer
City, State, Zip Code
Your answer
Phone
Your answer
Email
Your answer
How did you find us?
Your answer
Preferred Pronoun
You identify as...
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Relationship Status
Sexual Orientation
Children (please list names and aged, if relevant to treatment)
Your answer
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This form was created inside of Center. Report Abuse - Terms of Service